A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

Right radial pulse 4+, 80/min, palpated

Left radial pulse 1+, 80/min, palpated

Left radial pulse 4+, 80/min, palpated

Right radial pulse 2+, 80/min, palpated

Answer and Explanation

The Correct Answer is A

A. Right radial pulse 4+, 80/min, palpated:
A 4+ pulse is bounding, which is consistent with the nurse’s finding. HR is documented as 80 bpm.

B. Left radial pulse 1+, 80/min, palpated:
There is no indication that the left pulse is weak or thready (which would be 1+).

C. Left radial pulse 4+, 80/min, palpated:
The left radial pulse was described as expected, not bounding.

D. Right radial pulse 2+, 80/min, palpated:
A 2+ pulse is considered normal, but the right pulse was bounding, which corresponds to a 4+ rating.

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Correct Answer is A

Explanation

A. Choose a finger with a capillary refill less than 2 sec:
This ensures adequate peripheral perfusion, which is necessary for accurate pulse oximetry.

B. Obtain the oxygen saturation reading immediately after applying the sensor probe:
Wait a few seconds for the sensor to stabilize and detect accurate values.

C. Place the sensor probe on the same extremity as an electronic BP cuff:
A BP cuff can interfere with readings by restricting blood flow.

D. Relocate the sensor every 8 hrs:
Sensors should be relocated every 2–4 hours to prevent skin breakdown, especially in continuous monitoring.

A. Temperature of 39° C (102.2° F). B. Hypoglycemia C. Report of dizziness D. History of cigarette smoking

Correct Answer is C

Explanation

A. Temperature of 39°C (102.2°F):
Fever typically causes an increase in heart rate, not bradycardia.

B. Hypoglycemia:
Hypoglycemia is more commonly associated with tachycardia, sweating, and tremors, not bradycardia.

C. Report of dizziness:
Bradycardia (HR <60/min) can lead to decreased cardiac output and cerebral perfusion, causing dizziness.

D. History of cigarette smoking:
Smoking is associated with cardiovascular disease but not specifically bradycardia.

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A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

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Explanation

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Correct Answer is C

Explanation

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